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Déjà flu? Was 2009’s swine-flu panic occasioned by fears of 1918?

16 December 2009

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Medical Journalist

Steve lives in the Pennines in the heart of the Calder Valley. After a career in NHS management he became a fulltime writer in the 1990s. His PC contains 50,000 fascinating facts about the NHS. In the last year, Steve has climbed Ben Nevis, Mount Snowdon and Scafell Pike

Epidemic is a scary word. But much scarier is its big brother: pandemic. The Black Death in the 14th century was a pandemic, and everyone knows what happened then. So when the World Health Organization (WHO) starts to give daily reports on the progress of a Mexican epidemic in the process of becoming a global pandemic, governments sit up and take notice.

But has there been a gross over-reaction to the threat posed by H1N1 swine flu? Have practices and the public been pointlessly panicked? Has mass hysteria substituted for common sense – particularly so in England, compared to somewhat different responses in Scotland, Wales and Northern Ireland?

Swine flu – at least to date – has not turned out to be the apocalyptic event many predicted it could be. It is, however, worth recalling what a serious influenza pandemic can be like.

The lessons of history
Ninety years ago, influenza gave an awesome demonstration of what one of its more deadly strains can do. Towards the end of the First World War, a pandemic arose that decimated the population not just of Britain but the world.

Known as “Blitz Katarrh” by the Germans and as “Wrestlers’ Fever” by the Japanese, to the British and Americans it was “Spanish flu” or “the Spanish Lady”.

More people would die in one year during that influenza pandemic than had been killed in four years of armed conflict, during which tens of thousands of lives were sometimes lost in a single day.

Fewer than 10 million service men and women died in combat during the First World War. Yet 3% of the world’s population were killed in the influenza pandemic – up to
70 million people.

During a period of a mere three months, nearly 250,000 folk died in Britain. In Germany, there were 400,000 fatalities. A million died in the USA; incredibly, more Americans died of flu in 1918 and 1919 than all the US soldiers killed in the First and Second World Wars and in Korea and Vietnam combined.

Steam ships spread the disease at a slower pace than modern-day aircraft, but still the disease spread. In India, uncounted millions perished. In more remote spots such as the South Seas, where there was little or no previous exposure to flu, the death toll was, proportionately, even worse: one in four of the population died in Samoa. In some parts of Alaska, almost two in three of the Eskimo population died.

Four years ago, Dr Jeffrey Taubenberger of the Armed Forces Institute of Pathology, Maryland, analysed DNA from the virus found in the lungs of a female victim of the 1918 pandemic, whose body was buried in Alaskan permafrost. Dr Taubenberger discovered that the 1918 pandemic was caused by mutated avian flu – though whether it had originally passed into the human population directly from birds, or to humans via pigs, remains a still-unanswered question.

Without today’s vaccines or antiviral drugs, many sought the illusory protection of quack medicines and folk myths. Some sensibly took to wearing face masks; the less sensible took to carrying potatoes in their pockets or tying cucumbers to their ankles.

Peace broke out in November 1918, but the Spanish Lady continued to dance her fatal fandango.

British soldiers who had survived the battlefields of France now had the fruits of victory snatched from them. Many would return home only to find that the sweetheart who had waited for them for four long years was no longer among the living. Sickness soared. Industry was badly affected: trains did not run and coal supplies dwindled. For a time, the economy was all but paralysed.

In the spring of 1919, the death toll eventually began to decline. A milder wave of the flu appeared, only to be followed by a lethal encore in the autumn.

Facts and figures
Though the flu pandemic of 1918-19 was the worst ever recorded, it was unusual only in its severity. In fact, flu pandemics are common, if unpredictable: the intervals between recorded pandemics have varied from 11 to 42 years. Notably bad years for flu in more recent history were 1957 and 1968, when the world experienced, respectively, “Asian Flu” and “Hong Kong Flu”.

The global death toll from “Asian Flu” in 1957 is thought to have been around two million. In Britain, there were 33,000 “excess” deaths (the number of deaths above the range that would normally be expected). The less virulent pandemics of 1968, and the later “Russian Flu” of 1977, each resulted in a million deaths around the world – 30,000 of them in Britain.
Even in ordinary years, flu-related deaths still average 3-4,000 in the UK, despite millions of doses of flu vaccines now being routinely made available.

Vaccinating the elderly and other vulnerable people, such as those suffering from chronic renal and heart disease, diabetes and asthma, should reduce the death toll – but who exactly are the most vulnerable people?

Worryingly, it was not the old and frail who were most likely to succumb to the 1918 flu pandemic but the young and healthy. Young, fit servicemen were more likely to die than their parents.
The reason can be traced back to an event nearly 30 years earlier. In 1889, another flu pandemic had spread around the globe. Many old and frail people died. Younger folk, however, usually lived and in the process acquired some immunity to the 1918 virus, which it is supposed was a mutated version of the 1889 outbreak.

For governments and those charged with taking care of our welfare, the problem with influenza is that no one can predict what it will do next. Since 1997, for example, more than 16 outbreaks of H5 and H7 influenza have occurred among poultry, with the ever-present potential for escape into the human population.

Statistically, any single new flu strain is unlikely to be both lethal to humans and easily transmitted. But the lesson of 1918 is an awful one and should never be forgotten – not least in today’s world of mass international travel.

The bad news is that a new strain, such as the current outbreak of swine flu, can arise anywhere in the world – and today, unlike in the past, it can be spread to every part of the globe within weeks.

Planned response
Surprisingly then, until very recently the Department of Health’s (DH) worst-case planning scenario was of just 50,000 excess UK deaths from a flu pandemic. That’s a reasonable figure using the outbreaks in the last 50 years as a guide. The real worst-case scenario, however, is far worse than the pandemics of 1957, 1968 and 1977.

It was only in March 2007 that the Cabinet Office and the DH finally put their heads together and issued a consultation document acknowledging the possibility that the previous worst-case planning assumption of 50,000 deaths might be hugely underestimating the potential scale of the threat.

The Home Office’s “reasonable worse-case scenario” for a flu pandemic now anticipates “around 750,000 additional deaths across England and Wales, based on a clinical attack rate of 50% and a case fatality rate of 2.5%.”(1)

Coincidently, in a fanfare of publicity in early 2009, the WHO published brand-new phase descriptions of pandemics in its global preparedness plan. Almost immediately, in mid-April, the H1N1 variant appeared in Mexico. By 26 April, that flu variant had spread widely; with cases reported in Canada, the US, New Zealand, the UK, France, Spain and Israel.

On 29 April, the WHO raised the stakes to “worldwide pandemic phase 5”. On 11 June, it raised its classification to “phase 6”, meaning that H1N1 swine flu had officially reached pandemic proportions.

Another relatively new feature of the pandemic landscape was the availability of aggressively marketed drugs such as Tamiflu and Relenza. By mid summer, government warehouses were stuffed to overflowing with tens of millions of packs of Tamiflu, the antiviral drug that promised to stop influenza in its tracks.

The first UK case of swine flu was recorded in Scotland in April 2009. By mid June, 1,000 cases had been reported. By the end of July, cases peaked at 110,000 in one week, falling to 18,000 a week by early October, before beginning a predicted rise in autumn to nearly 80,000 by the end of the month.

Taking action
By the start of November, however, reported flu-related deaths had not reached the feared tens of thousands, but barely one hundred in England and less than 150 in the whole of the UK.
Perhaps the outbreak had been stopped in its tracks by public health adverts advising the public to wash their hands. Or perhaps the creation of the costly National Pandemic Flu Service telephone helpline in England had done the trick.

Or perhaps the whole exercise was a gross waste of time and money. Perhaps the government had merely been panicked into taking quite unnecessary measures by an overexcited media intent upon whipping up terror among the public.

Not all of the UK, however, responded in the same way. In Northern Ireland, the Swine Flu Helpline differed from that in England by not having collection points for prescriptions. Individuals ringing the helpline have simply been given advice on management of their symptoms and advised to phone their GP, or the out-of-hours service, for a prescription.

According to Northern Ireland practice manager Lorraine Hughes at the Brownlow Health Centre, Craigavon: “I think information/education to GPs and to the public, treatment of the illness, and pandemic-flu planning have been very good in Northern Ireland. The only criticism I would have is that there was such a lot of information being emailed to practices daily for several months that one tended to reach saturation point!”

More problematic has been the fact that vaccine supplies have only become available after Lorraine’s practice had already completed its normal flu clinics.

Meanwhile, Welsh Health Minister Edwina Hart announced that Wales would not be part of the National Pandemic Flu Service when it went live in England on 23 July. Instead, NHS Direct Wales would field all enquiries from the public. That decision was publicly endorsed by Dr David Bailey, Chairman of the British Medical Association’s GPs’ Committee in Wales.

Elsewhere, NHS 24, Scotland’s equivalent of NHS Direct, also opted out of the National Pandemic Flu Service. Instead, back in May, NHS 24 simply increased the number of staff operating its advice lines.

In England, however, hundreds of thousands of pounds of taxpayers’ money has allegedly been wasted after 1,200 workers were employed to deal with the expected deluge of anxious calls – enquiries that largely failed to materialise.
Two swine-flu call centres closed just weeks after opening, with staff reported to have been spending most of their time playing cards and board games. Has the whole exercise been pointless?

Maureen Pitchforth, a practice manager in Sowerby Bridge, West Yorkshire, has mixed views: “The National Pandemic Flu Service was not well organised at first, although it is now much improved and has certainly saved our practice some work.
“Even so, GPs probably could have managed this flu outbreak as part of their normal workload. Our biggest problem has been the late arrival of supplies of the swine-flu vaccine.”

For most people, swine flu has, so far, proved to be a relatively mild infection. The number of actual deaths has been statistically insignificant – despite the individual sadness accompanying every loss.

The pandemic, however, has been real enough. Swine flu has indeed swept the world. The WHO’s warning system has worked. And in Britain, the government’s plans to respond to a pandemic have been given a thorough testing.

Even so, the mass distribution of Tamiflu, an expensive advertising campaign and the establishment of costly call centres may have been an over-reaction to the threat. Yet any criticism must be balanced against questions that start with: “What if …?”

What if swine flu had been as virulent as the Spanish Lady? Or what if it is the next flu pandemic that turns out to be as devastating as that which spread around the globe in 1918?

Surely it’s better by far to have had the luxury of testing systems at relative leisure rather than testing them in the midst of a full-blown disaster? And happily, if nothing else, the DH has found an additional £47m with which to compensate GPs for the extra work that swine flu has created for them.